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BACKFLOWCERTIFICATION OF RE-CLAIMED WATER SYSTEMS gA RObj* CROSS CONNECTION SPECIALISTS BACKFLOW PREVENTION VALVE EXPERT CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS_,, �j INSTALLATION -REPAIRS -TESTING -CERTIFICATION •s'M BACKFLOW PREVENTION SPECIALISTS, INC, LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 464 -FLOW (3569) (408) 269-2600 3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356 3608 FERNV400D ST., SAN MATEO CA 94403 FAX (408) 269-2650 VACUUM BREAKERS - • SERVICE ADDRESS 10251 Torte Ave MAILING ADDRESS Civic Park -G, LLC 20725 Valley Green Dr., Ste. 100 Cupertino, CA 95014 MANUFACTURER MODELNUMBER TYPE Wilkins 3-25 po CONTACT LCI TEL# 262-141 SIZE 3" SERIAL NUMBER L207S2 INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 20956000 mtr# 36663593 domestic water EXTERNAL Tooj ' Gpp-/ 5 IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX 9 PASS qL FAIL❑ - THE ABOVE RE INITIAL TEST BY • REPAIRED BY ERTIFIED TESTER NO. 10466 DATE 11-22-04 MO. DAY YR. ,ATE I FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. I: REDUCED PRESSURE DEVICES PRESSURE TYPE ' DOUBLE CHECK VALVES VACUUM BREAKERS - RPP VALVES DIFFERENTIAL CHECK VALVE CHECK VALVE PRESSURE/RELIEF VALVE AIR INLET CHECK VALVE N0.1 N0.2 CLO D TIGHT �, CLOSED TIGHT �Q 22 � OPENED AT,LBS. OPENED AT _ LBS CLOSED TIGHT ❑ INITIAL # lbs. 4.D Ies. #LBS $ LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND MATERIALS USED FINAL CLOSED TIGHT C1 CLOSED TIGHT ❑ CLOSED TIGHT OPENED AT_LBS OPENED AT_LOS TEST $LBS $LBS #USS THE ABOVE RE INITIAL TEST BY • REPAIRED BY ERTIFIED TESTER NO. 10466 DATE 11-22-04 MO. DAY YR. ,ATE I FINAL TEST BY CERTIFIED TESTER NO. DATE MO. DAY YR. I: CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ��d°M CROSS CONNECTION SPECIALISTS CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT INSTALLATION -REPAIRS -TESTING -CERTIFICATION BACKFLOW PREVENTION SPECIALISbTS,NC, LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 464 -FLOW (3569) I 3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 (408)269-2d.00 DEC 0 rd 'L004 3608 FERNWOOD ST.. SAN MATEO CA 94403 FAX (408) 269-2650 F-1 L SERVICE ADDRESS 10251 Torre Ave., Cupertino/X-Rodrigues Ave. MAILING ADDRESS Civic Park -G, LLC CONTACT Leaundra 20725 Valley Green Dr., Ste. 100 TEL# 262-1418 Cupertino, CA 95014 MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER Wilkins '475 Y(— N 2" ' W187304 INTERNAL ❑ TAG LOCATION OF DEVICE Intr# 50014731 irrigation EXTERNAL IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX 01� PAS8�$ FAIL❑ THE ABOVE REPORT IS CERTIFIED TORE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 10466 DATE 11-22-04 DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR. REDUCED PRESSURE DEVICES PRESSURE TYPE DOUBLE CHECK VALVES VACUUM BREAKERS RPP VALVES DIFFERENTIAL CHECK VALVE CHECKVALVE PRESSURE/RELIEF VALVE AIR INLET CHECKVALVE NO.1 NO.2 CLOSED TIGHT` CLOSED TIGHT OPENED AT LBS. OPENEDAT_LBS CLOSED TIGHT ❑ INITIAL #lbs. lbs. *LBS #LBS. TEST OPENED UNDER 2.0 OPENED UNDER 1.0 LEAKED ❑ LEAKED ❑ OR DID NOT OPEN ❑ OR DID NOT OPEN ❑ LEAKED ❑ REPAIRS AND - MATERIALS USED FINAL CLOSED TIGHT ❑ CLOSED TIGHT ❑ CLOSED TIGHT ❑ OPENED AT LBS OPENED AT LBS TEST i LBS #LBS _ _ # LBS THE ABOVE REPORT IS CERTIFIED TORE TRUE INITIAL TEST BY • REPAIRED BY FINAL TEST BY CERTIFIED TESTER NO. 10466 DATE 11-22-04 DATE CERTIFIED TESTER NO. DATE MO. DAY YR. MO. DAY YR.